The American Board of Pediatric Neurological Surgery



The American Board of Pediatric Neurological SurgeryRequest for Recertification The completed request for recertification form should be submitted via e-mail to kbollerman@.Please read carefully and check (left click and then choose “checked”) the appropriate boxes. Application will not be processed until complete.Part I: Contact and Practice Information Name: Address: Institution: Street: City: State or Province: Zip or Postal Code: Country: Phone: Fax: E-mail: Current Institution: City: Date started practice at current Institution: FORMCHECKBOX No restrictions FORMCHECKBOX Restricted If restrictions, explain: ____________________________________________________________________________________________________________________________________________________________Part II: Professional Standing Have you received any type of sanction or are you currently FORMCHECKBOX Yes FORMCHECKBOX No under investigation by a hospital, state licensing agency, or other healthcare organization? Have you voluntarily or involuntarily surrendered, retired orrelinquished ANY licensure or registration? FORMCHECKBOX Yes FORMCHECKBOX NoHave you had or do you currently have successful challenges FORMCHECKBOX Yes FORMCHECKBOX No to your DEA or state-controlled substance registration? Have your privileges at ANY hospital or healthcare facility FORMCHECKBOX Yes FORMCHECKBOX Nobeen limited, reduced, suspended, diminished, revoked, or notrenewed by the action of any hospital or healthcare facility? Has your faculty membership at ANY medical center or other FORMCHECKBOX Yes FORMCHECKBOX NoProfessional school been removed or subject to disciplinary action?Are you currently Certified by the American Board of Neurological FORMCHECKBOX Yes FORMCHECKBOX NoSurgery or the Royal College of Surgeons (Canada)?If you answered YES to any of the questions numbered 1 through 5, please explain in the section immediately below: ____________________________________________________________________________________________________________________________________________________________Licensure Information STATE OR PROVINCE LICENSE NUMBER RESTRICTED OR SUSPENDED_____________________________________ FORMCHECKBOX Yes FORMCHECKBOX No _____________________________________ FORMCHECKBOX Yes FORMCHECKBOX No_____________________ ________________ FORMCHECKBOX Yes FORMCHECKBOX No_____________________ ________________ FORMCHECKBOX Yes FORMCHECKBOX No Supporting documentation accompanying this application. Please check off: ABNS Diplomates: FORMCHECKBOX ABPNS case log of all cases (adults and children) for the 12 months preceding ABPNS recertification application. Case log must be in ABPNS format (can be obtained at ). Case log must demonstrate at least 65 pediatric (age 21 and under) surgical cases over a 12 month time period and at least 85 total number of surgeries. FORMCHECKBOX Applicant must be current on ABNS CC process for the recertification year they are submitting application (ABPNS staff will verify this with the ABNS).RC Diplomates: FORMCHECKBOX Provide letter of good standing from current hospital/institution. FORMCHECKBOX Provide proof of completion of the ABNS-ABPNS Continuous Certification annual pediatric adaptive learning modules for recertification year (copy of completion certificate). FORMCHECKBOX Copy of Medical License in pdf format. FORMCHECKBOX Copy of RCPSC certificate in pdf format. FORMCHECKBOX ABPNS case log of all cases (adults and children) for the 12 months preceding ABPNS recertification application. Case log must be in ABPNS format (can be obtained at ). Case log must demonstrate at least 65 pediatric (age 21 and under) surgical cases over a 12 month time period and at least 85 total number of surgeries.Please note that the application must be completed and in the hands of the Credentialing Committee by April 1st for review at the June Board meeting or by October 1st for review at the December Board meeting. A recertification application fee in the amount of $375 is due at the time of application and payable on the ABPNS website. If your application is approved by the Board, you will be eligible for the joint ABNS-ABPNS focused practice document (certificate) once proof of completion of ABNS continuous certification requirements are met for your recertification year. If your application is incomplete or received after the deadline date, your application will be processed at the subsequent board meeting. Please submit this application and the supporting documentation listed above electronically via e-mail to kbollerman@.By signing below, I hereby verify that all information submitted in this application for recertification by the American Board of Pediatric Neurological Surgery is true, accurate and completed to the best of my knowledge and belief. I hereby request recertification by the American Board of Pediatric Neurological Surgery. I understand that recertification will require the submission of an operative case log and the successful completion of the ABNS continuous certification requirements. Electronically signed by: _____________________________ (type in your name to verify above)Date: ______________ABPNS Administrative Area only: Current Membership Status: _______________________________________ABPNS Expiration Date: ___________________________________________Case log provided in proper format in Excel format. No case log due to certified-inactive status. Paid Recertification Fee ABNS CC Status: _________________________________________________ ................
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